- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.46 / $105.46 / $105.46
| Facility | | $105.46 | $105.46 | $105.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.46 / $105.46 / $112.05
| Professional | | $105.46 | $105.46 | $112.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,452.73 / $3,549.39 / $6,139.22
| Facility | | $2,452.73 | $3,549.39 | $6,139.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $112.05
| Facility | | $112.05 | $112.05 | $112.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $112.05
| Professional | | $112.05 | $112.05 | $112.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.46 / $174.01 / $200.37
| Facility | | $105.46 | $174.01 | $200.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.29 / $486.29 / $486.29
| Professional | | $486.29 | $486.29 | $486.29 |